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� <br />Date�_�7 <br />Application For <br />PUBL.IC WiDRKS PERMIT <br />Print or Type Only <br />er <br />Applicant <br />Describe Proposed Work <br />'D'='�`=-c�_ �a <br />Mailing Address <br />Address <br />Public Works Pprmil ♦ �� � � ' <br />Ciltl9. DeP�. s _�l'� � �� <br />Publ¢WorksFee S <br />TolalFec -- <br />Less Ao01. F.,., Paln S� <br />o,��,,:�� � o���, S �� �� _ <br />� ���s_i_.; c,��� �rz �� _ Cv5 3— Za2S <br />Ci�! � Zip Phone <br />City Zip Phone <br />Project Address (if known) l�q� �� � 7�' lJfLJ t <br />Attach lour (4) copies ol plans for proposed work � Drew to scale and nole ;he following as applicable: <br />• Property Lines , O Centerline of street <br />• Outli��e and dimensions ot all existin� and O Indicate North <br />proposed strucWres on the lot • Show any proposed gradi�iq changes <br />• Existing and proposed utilities �e Show measurements <br />NOf <br />PE�:MIT CONDITIONS <br />t. Nr �. alls for inspection shall be made 24 hrs. in advance - phone 259•881 5. <br />2. All work shall be performed in accordance with this permit and current City of Everett Design and Construction <br />Standards and Specilicatior;. <br />3. Call Locatiqn Underc�round Service 48 hrs. belore you dig. TOLL FREE NUMBER 1-800•4245555. <br />. . i �. . '�. . � . .. � . .� .. � �� - <br />,.. , �,.,, . . ; _ . . ,, ...._,. <br />_.. <br />I�U1x�'-I� C��:r'ii.i` il��t .,, ,'t,.�� � <br />L.01' ^�f;RDE Ci-I,al`Ji:��' hiUSl :�G: ;iFF i:i:i <br />L.TC WOIzF 5 7!�15F'FCTOR. <br />C' �l'Y `37'R61-1'S I:L_I-AhI (;T i'�LL. 1 if,��7- <br />T^,LI_. ld(1 � i.F. ,':',OXES "(�! rl �:AI)L=. A i -• IE: <br />t.�:i'.;,�' i-;'(' �,'"id �'il,-:�� i�nri•c,l ' rl'_I '. ' t i-J', :'F 1'`. . <br />�i. <br />��\�(\ � 7 / <br />/ IUY-� ��-,C-Z'� L c �W/IJ�_ <br />Approved for Const ctio❑ Date <br />FINALINSPeCTION <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTME"IT <br />� 3200 Cedar Street <br />Everetl, WA 98201 <br />Phone:259-8815 <br />Date <br />� <br />� <br />rs <br />� <br />ACKNOWLE�GEMENT OF CONDITIONS <br />The undersigned owner/applican� hereby a9rees to hold and save harm- <br />Ir;s the City ot Everett irom any and all claims f�r damages, costs, <br />expanses, or causes of action that may arise because of installation <br />and mainterance of the improvemenl or other ric�ht-of-way use nereto <br />applied for and lurlher agrees lo remove same upon notice Iwm the <br />City and lo replace public proper�y damaqed lhereby. <br />�, �� „ ���� Q� <br />� :, �.«=.-� � , � <br />Si�nature of Applicant Date <br />WOFK AUTHORIZED BY THIS PERMIT MUST BE STARTED �NI'HItJ <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TJ <br />BE DILIGENTLY PURSUED TO CC `.iPLETION. THIS PERMIT MAY E E <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF l^/OFIi ('ii; T- d5 <br />PFOJcCT GVFR 90 DAYS DURATIO" <br />"�� <br />,%'";� <br />